A Pilot Randomized Controlled Trial of Text Messages to Improve Well-Child Visit Attendance After No-Show.

OBJECTIVE: Evaluate the effectiveness of text messages to systematically engage parents/guardians ("caregivers") to reschedule a well-child visit (WCV) that was missed ("no-show") and attend that rescheduled WCV visits. METHODS: Patients <18 years in one of five pediatrics or family medicine clinics, in one health system in the Southeast US, were eligible. Patients without a rescheduled WCV after a no-show were randomized into intervention (text messages) or care-as-usual comparison, stratified by language (English/Spanish). Enrollment occurred May-July 2022. Up to three text messages were sent to caregivers one week apart via REDCap and Twilio, advising how to reschedule the missed appointment by phone or health portal. Primary outcomes were 1) rescheduling a WCV within 6 weeks of no-show and 2) completing a rescheduled WCV within 6 weeks. Risk differences (RD) and odds ratios (OR) were used to evaluate the effect of text messages. RESULTS: Seven hundred and twenty patients were randomized and analyzed (texts: 361, comparison: 359). The proportion rescheduling WCV after text versus usual care was English: 18.85% versus 15.02%, respectively, and Spanish: 5.94% versus 8.14%, with overall RD+ 1.98% (95% CI: -1.85, 5.81) and OR 1.21 (95% CI: 0.79, 1.84; P-value .38). Completed WCV rates in text or usual care were English: 13.08% versus 6.59%, and Spanish: 5.81% versus 5.94% with texts associated with RD+ 2.83% (95% CI: 1.66, 4.00) and OR 1.86 (95% CI: 1.09, 3.19). CONCLUSION: Text message follow-up after a no-show WCV may positively impact attendance at WCVs rescheduled in the subsequent 6 weeks. TRIAL REGISTRATION: ClinicalTrials.gov NCT05086237.

Optimal site of care for administration of extended half-life respiratory syncytial virus (RSV) antibodies to infants in the United States (US).

INTRODUCTION: New extended half-life antibodies for the single-dose prevention of medically attended (MA) respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) have been developed for administration to all infants before or during their first RSV season. For infants born during the season, administration as soon as feasible after birth would provide optimal protection and minimize access disparities. The objective of this study was to assess the time from birth hospitalization discharge to the first outpatient visit (FOV) among US infants in order to determine optimal site of administration for the extended half-life antibody. MATERIAL AND METHODS: This retrospective, observational, time-to-event analysis uses the Merative™ MarketScan® Commercial and Multi-State Medicaid Databases. Time to FOV is reported separately for the COVID-19 and recent pre-COVID-19 eras and for commercially insured and Medicaid infants. RESULTS: Overall, 73.8 % of Medicaid infants had an FOV within 5 days as compared to 84.7 % of commercially insured infants. Estimates were higher during the COVID-19 era. Urban commercially insured infants had much higher FOV completion than their counterparts. Among Medicaid infants, urban Black and rural White infants were least likely to complete their FOV within 5 days of birth hospitalization discharge. DISCUSSION AND CONCLUSION: FOV within 5 days after birth hospitalization discharge for Medicaid infants is substantially lower than that of commercially insured infants. Approximately 1 in 4 Medicaid infants and 1 in 8 infants with commercial insurance did not have an outpatient visit within 5 days of birth hospitalization discharge. For US infants born during the RSV season, administration of extended half-life RSV antibodies in the newborn nursery prior to discharge would ensure optimal uptake and minimize access disparities.

Execution of anticipatory guidance and the knowledge and practice gap among caregivers in Southern Taiwan: A retrospective study.

BACKGROUND/PURPOSE: This study examined the practice rate of Anticipatory Guidance (AG) and the gap between knowledge and practice among caregivers. METHODS: We retrospectively collected data from caregivers who brought their children for seven age-based well-child visits (birth to 7 years old) and seven corresponding AG checklists for practice (each ranged from 16 to 19 guidance items, 118 items in total) between 2015 and 2017. Practice rates of guidance items and their association with children's sex, age, residence, and body mass index were collected and analyzed. RESULTS: We enrolled 2310 caregivers (330 per well-child visit). Average practice rates of guidance items in the seven AG checklists were 77.6%-95.1%, generally without significant differences between urban/rural or male/female children. However, lower (<80%) rates were observed for 32 items, including dental check-ups (38.9%), use of fluoride toothpaste (44.6%), screen time (69.4%), and drinking less sugar-sweetened beverages (SSBs) (75.5%), with corresponding knowledge-to-practice gap rates of 55.5%, 47.9%, 30.3%, and 23.8%, respectively. "Drinking less SSBs" was the only item with a higher obesity rate in the non-achieved group versus the achieved group (16.7% vs. 7.4%, p = 0.036; odds ratio: 3.509, 95% CI: 1.153-10.677, p = 0.027). CONCLUSION: Caregivers in Taiwan practiced most AG recommendations. However, dental check-ups, fluoride toothpaste use, drinking less SSBs, and limiting screen time were less executed items. A higher obesity rate was found among 3-7-year-old children whose caregivers failed to practice the "Drink less SSBs" guidance. Strategies to overcome the gap between knowledge and practice are needed to improve these less-achieved guidance items.

Multi-level quality improvement strategies to optimize HPV vaccination starting at the 9-year well child visit: Success stories from two private pediatric clinics.

HPV vaccination rates remain far below goal, leaving many adolescents unprotected against future HPV-related cancers. Starting HPV vaccine at age 9 may improve timely preteen vaccination. The "HPV Vax at 9" Quality Improvement intervention paired HPV vaccination with 9- and 10-year well child visits and was piloted at two pediatric clinics (n = 9 sites) in Washington between 2018 and 2022. Supporting interventions included standardized immunization schedule posters in exam rooms, electronic medical record supports, provider and staff training, strong provider recommendations, printed educational resources, and peer-to-peer champion coaching. Provider and clinic acceptance was high with HPV vaccine administration occurring at 68-86% of the 9- and 10-year well child visits. During the first year, HPV initiation rates at age 9-10 increased by 30% or more at each clinic. Sustained improvements in initiation and series completion were seen with completion at age 11-12 rising as much as 40% from 22 to 62%. Downward pressure of the COVID-19 pandemic on HPV vaccination rates was mitigated. Pairing HPV vaccine with 9- and 10-year well child visits, posting the standardized immunization schedule, and instituting EMR supports for HPV at 9 may be effective and sustainable strategies to simplify clinic workflows and increase timely HPV vaccination.

'Caregivers' awareness matters': Call for a child-centred approach to early detection of autism spectrum disorder through well-child visits in Japan.

BACKGROUND: Early detection of autism spectrum disorder (ASD) is essential to provide children with timely treatment and support. Evidence-based screening measures make it possible to identify children with suspected ASD at an early stage. Although Japan has a universal healthcare system that covers well-child visits, detection rates of developmental disorders, including ASD, at 18 months vary widely between municipalities (0.2%-48.0%). The reasons for this high level of variation are poorly understood. The present study aims to describe the barriers and facilitators of incorporating ASD identification during well-child visits in Japan. METHODS: This is a qualitative study that conducts semi-structured in-depth interviews in two municipalities of Yamanashi Prefecture. We recruited all public health nurses (n = 17) and paediatricians (n = 11) involved in the well-child visit in each municipality and caregivers of children who also participated in the visits during the study period (n = 21). RESULTS: We identified four themes characterizing the process of ASD identification in the target municipalities: (1) Identification of children with ASD is driven by caregivers' sense of concern, acceptance and awareness. (2) Multidisciplinary cooperation and shared decision-making is limited. (3) Skills and training for developmental disabilities screening are underdeveloped. (4) Caregivers' expectations shape the interaction in important ways. CONCLUSIONS: Non-standardization of screening methods, limited knowledge and skills on screening and child development among healthcare providers and poor coordination among healthcare providers and caregivers are the main barriers to effective early detection of ASD through well-child visits. The findings suggest the importance of promoting a child-centred care approach through the application of evidence-based screening measures and effective information sharing.

Predicting Childhood Obesity Based on Single and Multiple Well-Child Visit Data Using Machine Learning Classifiers.

Childhood obesity is a public health concern in the United States. Consequences of childhood obesity include metabolic disease and heart, lung, kidney, and other health-related comorbidities. Therefore, the early determination of obesity risk is needed and predicting the trend of a child's body mass index (BMI) at an early age is crucial. Early identification of obesity can lead to early prevention. Multiple methods have been tested and evaluated to assess obesity trends in children. Available growth charts help determine a child's current obesity level but do not predict future obesity risk. The present methods of predicting obesity include regression analysis and machine learning-based classifications and risk factor (threshold)-based categorizations based on specific criteria. All the present techniques, especially current machine learning-based methods, require longitudinal data and information on a large number of variables related to a child's growth (e.g., socioeconomic, family-related factors) in order to predict future obesity-risk. In this paper, we propose three different techniques for three different scenarios to predict childhood obesity based on machine learning approaches and apply them to real data. Our proposed methods predict obesity for children at five years of age using the following three data sets: (1) a single well-child visit, (2) multiple well-child visits under the age of two, and (3) multiple random well-child visits under the age of five. Our models are especially important for situations where only the current patient information is available rather than having multiple data points from regular spaced well-child visits. Our models predict obesity using basic information such as birth BMI, gestational age, BMI measures from well-child visits, and gender. Our models can predict a child's obesity category (normal, overweight, or obese) at five years of age with an accuracy of 89%, 77%, and 89%, for the three application scenarios, respectively. Therefore, our proposed models can assist healthcare professionals by acting as a decision support tool to aid in predicting childhood obesity early in order to reduce obesity-related complications, and in turn, improve healthcare.

Well Child Wednesdays: An interprofessional pilot-program to increase pediatric immunizations Post-COVID.

Background: The COVID-19 pandemic halted routine medical care, including well-child visits (WCVs) and immunizations. Purpose: Describe the development and impact of a multidisciplinary initiative on the number of WCVs and immunizations delivered in aftermath of the COVID-19 pandemic over a four week period between April 14, 2021 and May 5, 2021. Methods: Student pharmacists (SP), family medicine residents (FMRs), and nurses within a family medicine practice in a medically underserved community, developed a program to increase the number of pediatric patients up-to-date on WCVs and immunizations. "Well-child Wednesdays" used adjusted staffing to conduct visits with patients behind on vaccines. The 4-week pilot program utilized SPs to identify immunization gaps in patients less than 12 years old following chart review and to coordinate scheduling. During the visit, FMRs completed the components of the well-child visit; immunization gaps were communicated to the nurse who, after review, administered needed immunizations. Discussion: Of 193 patient charts reviewed for immunization needs, 68 were not up-to-date on routine vaccines and 29 patients (mean age 5 years old, 58.6% male) were able to be reached and agreed to schedule a visit. Of these, 20 kept their appointment and a total of 69 vaccines were administered, with DTaP as the most common with 13 doses administered followed by Hepatitis A with 10 doses given. Conclusions: An interprofessional immunization program was an effective strategy to address the decline in immunizations and WCVs as a result of COVID-19.

Parents' Adherence to Childhood Screening Tests and Referrals: A Retrospective Cohort Study with Randomized Sampling.

Routine timely examinations of well-child health are important for achieving children's good health outcomes. Nevertheless, there is evidence of low compliance with well-child visit recommendations. The aim of the study was to examine potential factors associated with parents' nonadherence to routine childhood screening tests and their acting on further referrals following unusual findings. A retrospective cohort study was conducted among 14,348 children born in 2016-2017 and registered at mother-child health clinics in a large city in Israel. A sample of 844 children was randomly selected. Screening tests at the age of two months and nine months were examined. A multiple logistic regression examined potential factors associated with nonadherence to screening tests and to further referral for evaluation. Lower adherence to screening tests was found among parents of nine-month-old children, but adherence was higher for nurses' screening tests than for those of physicians. Children born in a complex delivery process, older mothers with a higher number of children, and Israeli citizens were at risk of not undergoing screening tests. Fewer children in the family and initial physician's findings were the only explanation for acting to referrals. In order to promote children's health outcomes and public health, health policymakers should conduct campaigns to convince parents of the importance of screening tests and of adherence to referrals with the aim of ensuring their children's wellbeing throughout the life cycle.

Video-Based Anticipatory Guidance on Early Cognitive and Language Development in the First 6 Months: A Randomized Controlled Trial.

This randomized controlled trial showed that video-based anticipatory guidance implemented at well-child visits in the first 6 months increased knowledge of early cognitive and language development (P < .001), which in turn promoted cognitive growth fostering behaviors among parents of low socioeconomic status (95% CI 0.09-0.57). TRIAL REGISTRATION: ClinicalTrials.gov: NCT02812017.

The Effect of Well Child Visit Location on Preventative Dental Visit.

Recent emphasis has been placed on the integration of dental and medical primary care in an effort to promote recommendations from both American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD) that highlight the importance of preventing, intervening, and managing oral disease in childhood. The study aims to provide a population level insight into the role of location of service of medical well-child visit (WCV) and its association to preventative dental visit (PDV) for children between the ages of 0-20 years. Administrative claims data for 3.17 million Medicaid-enrolled children aged 0 to 20 years of age in 13 states in 2016 and 2017 were identified from the IBM Watson MarketScan Medicaid Database. Descriptive and survival analysis reveals most Medicaid enrolled children receive their WCV at an office and hospital, as compared to federally qualified health center, or rural or public health clinic. Further, this study demonstrates increased utilization of dental preventive services for children who receive a WCV. Hispanic children, female children, and children 5-9 years of age had a higher rate of PDV after a WCV at all three locations. This study contributes to the understanding of medical-dental integration among Medicaid-enrolled children and offers insight into the promotion of oral health prevention within medical primary care.

A Health-Literacy Intervention for Early Childhood Obesity Prevention: A Cluster-Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Children who become overweight by age 2 have greater risk of long-term obesity and health problems. The study aim was to assess the effectiveness of a primary care-based intervention on the prevalence of overweight at age 24 months. METHODS: In a cluster-randomized trial, sites were randomly assigned to the Greenlight intervention or an attention-control arm. Across 4 pediatric residency clinics, we enrolled infant-caregiver dyads at the 2-month well-child visit. Inclusion criteria included parent English- or Spanish-speaking and birth weight ≥1500 g. Designed with health-literacy principles, the intervention included a parent toolkit at each well-child visit, augmented by provider training in clear-health communication. The primary outcome was proportion of children overweight (BMI ≥85th percentile) at age 24 months. Secondary outcomes included weight status (BMI z score). RESULTS: A total of 459 intervention and 406 control dyads were enrolled. In total, 49% of all children were overweight at 24 months. Adjusted odds for overweight at 24 months (treatment versus control) was 1.02 (95% confidence interval [CI]: 0.63 to 1.64). Adjusted mean BMI z score differences (treatment minus control) were -0.04 (95% CI: -0.07 to -0.01), -0.09 (95% CI: -0.14 to -0.03), -0.19 (-0.33 to -0.05), -0.20 (-0.36 to -0.03), -0.16 (95% CI: -0.34 to 0.01), and 0.00 (95% CI -0.21 to 0.21) at 4, 6, 12, 15, 18, and 24 months, respectively. CONCLUSIONS: The intervention resulted in less weight gain through age 18 months, which was not sustained through 24 months. Clinic-based interventions may be beneficial for early weight gain, but greater intervention intensity may be needed to maintain positive effects.

Recruitment strategies for a pragmatic cluster randomized oral health trial in pediatric primary care settings.

OBJECTIVES: To describe multilevel recruitment strategies for an ongoing clinical trial in pediatric primary care settings, and assess adoption and reach of these strategies via the RE-AIM framework. METHODS: This study is part of a larger pragmatic cluster randomized clinical trial focused on the effectiveness of interventions on the practice, provider, and caregiver levels on dental utilization for Medicaid-enrolled 3-6 year old children. Pediatric practices were recruited according to the proportion of Medicaid-eligible children, geographic region, and County. In accordance with the RE-AIM framework, providers reached were those approached directly and consented, and those who participated in the intervention training adopted to deliver the intervention. Caregivers reached were those approached and consented at their child's well-child visit to participate in the trial. RESULTS: Recruitment goals were met over a 21 month period, with an overall enrollment of 18 practices, 62 providers, and 1024 caregivers-child dyads. The majority of practices enrolled were small, suburban, and located in an urban county. The participation rates among approached providers and caregivers was 93% and 84% respectively. Enablers for recruitment was the one-on-one interaction with the provider and caregivers. Barriers to recruitment for caregivers included no-shows and cancellations at well-child visits. Adoption of intervention among providers was high, and caregiver reached were representative of the eligible target population. CONCLUSIONS: Active approaches to recruitment, such as utilizing opinion leaders, in-person recruitment, and building relationships with practice staff, can result in successful enrollment and imp lementation of a multi-level intervention in pediatric primary care settings.

Influence of a One-Time Web-Based Provider Intervention on Patient-Reported Outcomes After the Well-Child Visit: A Feasibility Study.

PURPOSE: Patient-centered care promotes positive health outcomes in pediatrics. We created a provider-focused intervention and implemented it in a pragmatic clustered randomized controlled trial to improve health-related quality of life (HRQOL) among pediatric patients. METHODS: A one-time (1-1.5-hour) webinar focusing on patient-centered care and motivational interviewing, using obesity screening as an example, was developed. Pediatric providers were recruited and randomized to either intervention (webinar) or control (usual care) arms. All well-child visits to these providers for a period of up to 5 months following webinar completion (or study enrollment for controls) were identified, and these family/patients were invited to complete a survey to assess HRQOL postvisit. Reported outcomes were compared between intervention and control participants using clustered t-tests, chi-squared tests and multiple linear regression models. RESULTS: We recruited 20 providers (10 intervention, 10 control) to the study; 469 parents/guardians and 235 eligible children seeing these providers completed the postvisit survey. Parents/guardians of 8-12-year-old children in the intervention group reported higher school functioning compared to controls (83.5 vs 75.8; P=0.023). There were no other differences in children's HRQOL between intervention and control groups. CONCLUSIONS: A one-time, web-based provider intervention is feasible to implement in pediatrics. Modest evidence, requiring further study, indicates that instructing providers on patient-centered care in the well-child visit may improve aspects of pediatric HRQOL (ie, school functioning) compared to usual care. However, this was a brief intervention, with multiple outcomes tested and no evaluation of pre- and postintervention provider knowledge, thus additional study is needed.

Rural Disparities in Early Childhood Well Child Visit Attendance.

PURPOSE: Children should attend well child visits (WCVs) during early childhood so that developmental disorders may be identified as early as possible, so treatment can begin. The aim of this research was to determine if rurality impacts access to WCV during early childhood, and if altering rurality measurement methods impacts outcomes. DESIGN AND METHODS: We utilized a longitudinal correlational design with early childhood data gathered from the Virginia All Payer Claims Database, which contains claims data from Medicaid and the majority of Virginia commercial insurance payers (n = 6349). WCV attendance was evaluated against three rurality metrics: a traditional metric using Rural-Urban Commuting Area codes, a developed land variable, and a distance to care variable, at a zip code level. RESULTS: Two of the rurality methods revealed that rural children attend fewer WCVs than their urban counterparts, (67% vs. 50% respectively, using a traditional metric; and a 0.035 increase in WCV attendance for every percent increase in developed land). Differences were attenuated by insurance payer; children with Medicaid attend fewer WCVs than those with private insurance. CONCLUSIONS: Young children in rural Virginia attend fewer WCVs than their non-rural counterparts, placing them at higher risk for missing timely developmental disorder screenings. The coronavirus disease pandemic has been associated with an abrupt and significant reduction in vaccination rates, which likely indicates fewer WCVs and concomitant developmental screenings. Pediatric nurses should encourage families of young children to develop a plan for continued WCVs, so that early identification of developmental disorders can be achieved.

The Strengths and Difficulties Questionnaire is a usable way to address mental health at well-child visits in general practice - a qualitative study of feasibility.

BACKGROUND: Mental health problems is frequent among children and psychopathology in early childhood seems to predict mental disorders in adulthood. All Danish children are offered seven free well-child visits at their General Practitioner (GP) during their first 5 years of life. GPs have a unique position to address mental health problems at the well-child visits, but they lack a systematic approach when assessing children's mental health. The purpose of this study was to investigate if the Strengths and Difficulties Questionnaire (SDQ) is a usable way to address preschool children's mental health in general practice. METHODS: A qualitative study of feasibility. Parents completed an online version of the SDQ at home. At the well-child visit, the GP used the SDQ results as a basis for a talk about the child's mental health. Afterwards the author JS conducted semistructured interviews with both the parent and the GP over the phone. The interviews were descriptively analyzed using the Framework Approach. RESULTS: Five primary care centres with 22 general practitioners in both Copenhagen and Region Zealand participated. Twenty four parents completed the SDQ and were interviewed. Participating parents and GPs agreed, that the SDQ introduced mental health as a natural and important part of the well-child visit. Online access had clear advantages: time for reflection at home and preparation, plus a clear result summary for the GP. Some of the GPs were worried that the questionnaire would be too time consuming, and might compromise the individualistic style of general practice. Some parents were worried if children with minor problems would be diagnosed. CONCLUSIONS: The online SDQ was well-accepted and feasible in daily practice. Implementing the SDQ into the well-child visit could strengthen the focus on the child's mental health. However, before the SDQ can be generally implemented a guideline on how to utilize it in the well-child visit is needed, as well as studies of efficacy in this setting. TRIAL REGISTRATION: Not relevant.

How an Electronic Medical Record System Facilitates and Demonstrates Effective Psychosocial Screening in Pediatric Primary Care.

Using questionnaires, administrative claims, and chart review data, the current study explored the impact of using an electronic medical record system to administer, score, and store the Pediatric Symptom Checklist (PSC-17) during annual pediatric well-child visits. Within a sample of 1773 Medicaid-insured outpatients, the electronic system demonstrated that 90.5% of cases completed a PSC-17 screen electronically, billing codes indicating a screen was administered agreed with the existence of a questionnaire in the chart in 98.8% of cases, the classification of risk based on PSC-17 scores agreed with the classification of risk based on the Current Procedural Terminology code modifiers in 72.9% of cases, and 90.0% of clinicians' progress notes mentioned PSC-17 score in treatment planning. Using an electronic approach to psychosocial screening in pediatrics facilitated the use of screening information gathered during the clinical visit and allowed for enhanced tracking of outcomes and quality monitoring.

Caring for the mother-child dyad as a family physician.

Infant social, emotional and neurological development is shaped by the mother-child dyad. Dysfunction in this bond, as well as maternal mental health problems, can negatively impact child development. The family physician is well-placed to spot dysfunction in the mother-child dyad and screen for postnatal depression during well-child visits. If any issues are identified, the family physician can provide support and help the mother-child dyad to access community resources and specialist psychiatric services.

Caring for the mother-child dyad as a family physician

Infant social, emotional and neurological development is shaped by the mother-child dyad. Dysfunction in this bond, as well as maternal mental health problems, can negatively impact child development. The family physician is well-placed to spot dysfunction in the mother-child dyad and screen for postnatal depression during well-child visits. If any issues are identified, the family physician can provide support and help the mother-child dyad to access community resources and specialist psychiatric services.

Providers' preferences for pediatric oral health information in the electronic health record: a cross-sectional survey.

BACKGROUND: The majority of primary care physicians support integration of children's oral health promotion and disease prevention into their practices but can experience challenges integrating oral health services into their workflow. Most electronic health records (EHRs) in primary care settings do not include oral health information for pediatric patients. Therefore, it is important to understand providers' preferences for oral health information within the EHR. The objectives of this study are to assess (1) the relative importance of various elements of pediatric oral health information for primary care providers to have in the EHR and (2) the extent to which practice and provider characteristics are associated with these information preferences. METHODS: We surveyed a sample of primary care physicians who conducted Medicaid well-child visits in North Carolina from August - December 2013. Using descriptive statistics, we analyzed primary care physicians' oral health information preferences relative to their information preferences for traditional preventive aspects of well-child visits. Furthermore, we analyzed associations between oral health information preferences and provider- and practice-level characteristics using an ordinary least squares regression model. RESULTS: Fewer primary care providers reported that pediatric oral health information is "very important," as compared to more traditional elements of primary care information, such as tracking immunizations. However, the majority of respondents reported some elements of oral health information as being very important. Also, we found positive associations between the percentage of well child visits in which oral health screenings and oral health referrals are performed and the reported importance of having pediatric oral health information in the EHR. CONCLUSIONS: Incorporating oral health information into the EHR may be desirable for providers, particularly those who perform oral health screenings and dental referrals.